DECISION AND ORDER

The issue in this case is whether the SCD Back & Joint Clinic (Provider) should be reimbursed for the cost of services rendered to the Claimant from January 12, 2001 to September 18, 2001. The Administrative Law Judge finds the Provider is entitled to $240.

I. Discussion

The Claimant suffered a work-related back injury on________. Soon thereafter, he underwent physical therapy, work hardening and a pain management program. On April 16, 1996, the Claimant started seeing the Provider. Since that time he has received extensive services from the Provider, including passive and active chiropractic modalities. The services in question span from January 12, 2001 through September 18, 2001, totaling eighteen dates of service. The Provider’s documentation reflects that on each date of service the Claimant saw the Provider for about 30 minutes and discussed his status. He was able to have questions answered regarding his pain and his home exercise program. At the beginning of each date of service the Claimant reported pain of six on a ten-point scale. After his consultation with the Provider, the Claimant reported a reduction of pain of one or two points. The Provider also administered one manipulation on one date of service and range of motion testing for which he also seeks reimbursement.

The Carrier denied the services based upon either the lack of medical necessity, lack of documentation, and for several dates of service, lack of compensability. The Medical Review Division of the Texas Workers’ Compensation Commission denied all of the Provider’s claims for reimbursement.

The Provider argues primarily that the services provided relieved the Claimant’s pain every day that he was seen and this reported reduction in pain is, in and of itself, sufficient to entitle the Provider to reimbursement under Tex. Lab. Code. Ann. § 408.021 (Vernon 1996). The Provider also maintains that the Claimant’s diabetes, depression and high blood pressure have complicated his treatment and delayed his recovery. David Bailey, D.C., who provided the treatment to the Claimant, testified that talking to a doctor helped the Claimant and relieved his pain every visit. The Provider also argues that the Carrier should not have denied claims under the “E” code because the injury was compensable.

The Carrier argues that all of the treatments were unnecessary and that it should not be required to provide reimbursement. It submitted a report prepared by Casey Cochran, D.O., who reviewed the medical records and believed that the treatment was not reasonable, necessary, or supportable by the medical documentation.

Dr. Cochran further noted that the range of motion testing reflected anatomic impossibilities and improbabilities and brought into question its value.

The ALJ agrees with the Carrier that the treatment provided was not medically necessary. The Claimant’s status remained virtually unchanged during the entire treatment period. Reported pain relief resulting from a thirty minute conversation is not sufficient evidence to establish necessity for these treatments. While Claimants are entitled to treatment for chronic pain, it should be delivered pursuant to a treatment plan, supported by clear explanation and documentation demonstrating why the treatment is necessary and what gains are to be expected. The Provider’s treatment records vary little from session to session and demonstrate that very few services were actually delivered short of conversation.

The ALJ agrees with the Provider that the Carrier wrongly denied certain claims under the “E” code. There is no evidence that the Claimant’s injury was not compensable. Therefore, the Carrier shall reimburse all claims denied under the “E” code, but the ALJ upholds the other denials for lack of documentation and medical necessity.

II. Findings of Fact

1. The Claimant sustained a compensable back injury on________.
2. Liberty Mutual Fire Insurance Company denied payment for treatment rendered January 12, 2001 to September 18, 2001. For each service provided the Carrier used one of the following codes for denial: “U”(not medically necessary), “N” (not appropriately documented) or “E” (not compensable).
3. Office visits on June 21, 2001; July 5, 2001; July 12, 2001; August 9, 2001; and August 17, 2001 were denied for lack of compensability under the “E” code.
4. The SCD Back & Joint Clinic filed three separate requests for dispute resolution with the Medical Review Division of the Texas Workers’ Compensation Commission (MRD). The MRD issued three separate decisions, each of which found that the Provider was not entitled to any reimbursement.
5. The Provider appealed two of the MRD decisions on March 19, 2002 and the third on June 6, 2002.
6. Notices of hearing were sent on May 7, 2002 for two of the matters, and July 10, 2002 for the third. The notices contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
7. On July 8, 2002, the matters were consolidated for hearing.
8. The hearing was convened on September 24, 2002 with Administrative Law Judge (ALJ) Janet Dewey presiding and representatives for the Carrier and Provider participating. The hearing was recessed at the request of the Carrier and with agreement of the Provider and reconvened on March 11, 2003. The record closed the same day.
9. From January 12, 2001 through September 18, 2001, the Claimant visited the Provider eighteen times.
10. On each date of service the Claimant saw the Provider for about 30 minutes and discussed his status. He was able to have questions answered regarding his pain and his home exercise program. At the beginning of each date of service the Claimant reported pain of six on a ten-point scale. After his consultation with the Provider, the Claimant reported a reduction of pain of one or two points. The Provider also administered one manipulation on one date of service and range of motion testing.
11. The services were provided to the Claimant on an “as needed” basis; however, there was no treatment plan, and short of some reported pain relief at the end of his thirty minute conversations with the Provider, the Claimant’s overall condition did not improve.
12. The Claimant has received six years of conservative care, including over four years of care from this Provider.
13. The results of the range of motion testing performed contained anatomical impossibilities and improbabilities.
14. The amount of reimbursement for the services contained in Finding of Fact No. 3 is $240.
15. All other services provided to the Claimant were not medically necessary.

III. Conclusions of Law

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(k) (Vernon Supp. 2003) and Tex. Gov’t Code Ann. Ch. 2003 (Vernon 2000 and Vernon Supp. 2003).
2. The Provider timely filed its request for a hearing as specified in 28 Tex. Admin. Code (TAC) § 148.3.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052 (Vernon 2002).
4. The Provider has the burden of proof in this matter. 28 TAC §148.21(h).
5. The Carrier failed to prove the services identified in Finding of Fact No. 3 were not compensable.
6. The Provider did not meet its burden of proving that all other services were medically necessary or reasonably required health care under Tex. Lab. Code Ann.§ 408.021, and these claims should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Lumbermans Underwriting Alliance shall reimburse the SCD Back & Joint Clinic $240. All other claims for reimbursement are DENIED.

Signed May9th, 2003

JANET R. DEWEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS